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American Family Physician, the journal of the American Academy of Family Physicians, has a feature called AFP Journal Club, where physicians analyze a journal article that either involves a hot topic affecting family physicians or busts a commonly held medical myth. In the September 15, 2010 issue they discussed “Vaccines and autism: a tale of shifting hypotheses,” by Gerber and Offit, published in Clinical Infectious Diseasesin 2009.

Gerber and Offit reviewed 13 large-scale studies that demonstrated no association between the MMR vaccine and autism. These included ecologic studies, retrospective observational studies and prospective observational studies. The findings were consistent; the only outlier in all the studies of MMR was Dr. Andrew Wakefield’s small, discredited 1998 study, which was fully retracted by The Lancet in early 2010.

They reviewed 7 large-scale studies (again, ecologic, retrospective, and prospective) that consistently demonstrated no association between thimerosal and autism. They showed that the hypothesis was not biologically plausible, since the symptoms of mercury poisoning are distinct from those of autism and are not produced by the thimerosal in vaccines.

They showed that the overload hypothesis is not credible because

The immunologic load has dropped from 3000 components in the 7 vaccines used in 1980 to less than 200 in the 14 vaccines recommended today.

An infant’s immune system is capable of handling the thousands of antigens it is exposed to early in life.

Joseph Mercola, along with Rosemary Fischer, are promoting vaccine awareness week this week, Nov 1-7. David Gorski, who edits Science-Based Medicine with me, thought it would be a good idea to go along with this and participate fully in vaccine awareness week. So all week we will be focusing on vaccine issues, and doing our best to counter any misinformation.

Mercola, who runs a highly commercialized website, chock full of health misinformation and anti-SBM propaganda, has started off the week with a broadside against the flu vaccine in an article titled: “New Proof that This Common Medical Treatment is Unnecessary and Ineffective”. He gives a Gish Gallop of error and misdirection – far more bits of falsehood than I have time to counter here. That’s the point of the Gish Gallop, it is far easier to create a misconception than it is to correct it. So if you throw enough mud at a topic you can overwhelm any attempt to defend accurate information, and leave your audience with the uneasy feeling that something must be wrong. In the case of Duane Gish his target was the science of evolution. With Mercola it is accurate health information.

Ironically, he starts off:

Armed with the facts, less than one-third of the US population fell for fear mongering. And together, we can do it again.

He accuses health officials of “fear mongering” – his word for warning people about the risks of the flu and recommending the flu vaccine. Of course, if you are interested in propaganda you can use this term to refer to any and every public health campaign. He picks on the H1N1 Pandemic of 2009 – an easy target. He plays Monday morning quarterback, pointing out that the pandemic was not as bad as projected. Again, it is easy to criticize officials for caution when the worst-case scenario does not unfold. When faced with a possible pandemic officials need to prepare for a plausible worst-case scenario, and then hope it doesn’t happen. What happened in 2009/2010 flu season is that the H1N1 flu showed up, but the regular seasonal flu didn’t, and so the total number of total flu cases was less than a typical year. We still don’t have an explanation for this, but it was completely unexpected. No one predicted this – not even the Mercola’s of the world.

After accusing health officials of fear mongering, Mercola then goes onto to relentlessly fear monger about an effective public health intervention – the flu vaccine. Remember his fear mongering from last year? Wasn’t the H1N1 vaccine supposed to cause an epidemic of Guillaine Barre Syndrome (GBS)? Well – it didn’t, and there was a careful surveillance program in place in the UK and US to monitor for any increase in GBS and it never occurred.

Now Mercola is at it again, and his stated goal is to scare people off the flu vaccine. He doesn’t expect to be held accountable for his dire predictions and misinformation – he just dumps as many bits of scary misinformation as he can and then moves on. Again – I can’t get to them all, but here are a few:

“Health officials have leapt ahead with recommendations of “flu shots for all” withoutsafety studies—so by getting a flu shot, you are effectively offering yourself up as a laboratory rat. In other words, YOU are the safety study!”

This is a transparent falsehood. Simply put “flu vaccine safety” into PubMed.org and see how many studies come up. There are many studies looking at the safety and side-effect profile of various flu vaccines in the general and in specific medical populations, including the effects of adjuvants, and simultaneous vs serial vaccination. There is a serious attempt by medical scientists to evaluate the safety and effectiveness of flu vaccines. But Mercola needs you to believe that there is a dark conspiracy and you need him to open your eyes and give you the real information – all you have to do is subscribe to his site.

Australia’s flu season precedes ours, so we can look to them for a preview of vaccine issues. By June of 2010, more than 1,000 adverse reactions in children under the age of 5 resulted in the Australian government’s banning of flu vaccines for that age group. High fevers, vomiting and convulsions were the most widely reported reactions, which are also associated with long-term adverse health outcomes.

CSL’s Fluvax appears to be the main troublemaker. However, CSL has objected to being singled out, claiming any of the other three vaccines on the Australian market could be to blame.

Notice the spin Mercola puts on this news item – he implies that any trivalent flu vaccine can be to blame, CSL says so (since when does he listen to a vaccine manufacturer?). The real story is that there was an increase in fever and other complications from one brand of flu vaccine in Australia – Fluvax. The increase occurred in that brand only. It was not a single-batch problem, and so this was likely a manufacturing

. For this reason the vaccine was temporarily suspended until the facts could be sorted out.

What are the implications for the US? The CDC has recommended that the Afluria vaccine – CSL’s vaccine for the North American market, not be used in children 6 months to 4 years old. That seems like a reasonable precautionary measure. And here we can see the difference between reasonable caution and hysterical fear mongering.

We write a lot about vaccines here at Science-Based Medicine. Indeed, as I write this, I note that there are 155 posts under the Vaccines category, with this post to make it 156. This is third only to Science and Medicine(which is such a vague, generic category that I’ve been seriously tempted to get rid of it, anyway) and Science and the Media. There is no doubt that vaccines represent one of the most common topics that we cover here on SBM, and with good reason. That good reason is that, compared to virtually any other modality used in the world of SBM, vaccines are under the most persistent attack from a vocal group of people, who, either because they mistakenly believe that vaccines caused their children’s autism, because they don’t like being told what to do by The Man, because they think that “natural” is always better to the point of thinking that it’s better to get a vaccine-preventable disease in order to achieve immunity than to vaccinate against it, or because a combination of some or all of the above plus other reasons, are anti-vaccine.

“Anti-vaccine.” We regularly throw that word around here at SBM — and, most of the time, with good reason. Many skeptics and defenders of SBM also throw that word around, again with good reason most of the time. There really is a shocking amount of anti-vaccine sentiment out there. But what does “anti-vaccine” really mean? What is “anti-vaccine”? Who is “anti-vaccine”?

Given that this is my first post for SBM’s self-declared Vaccine Awareness Week, proposed to counter Barbara Loe Fisher’s National Vaccine Information Center’s and Joe Mercola’s proposal that November 1-6 be designated “Vaccine Awareness Week” for the purpose of posting all sorts of pseudoscience and misinformation about “vaccine injury” and how dangerous vaccines supposedly are, we decided to try to coopt the concept for the purpose of countering the pseudoscience promoted by the anti-vaccine movement. To kick things off, I thought it would be a good idea to pontificate a bit on the topic of how to identify an anti-vaxer. What makes an anti-vaxer different from people who are simply skeptical of vaccines or skeptical of specific vaccines (for instance, the HPV vaccine)? I don’t pretend to have the complete answer, which is why I hope we’ll have a vigorous discussion in the comments.

Believe it or not, I’m actually a relative newcomer to the task of taking on the anti-vaccine movement. Ten years ago, I was blissfully unaware that such a movement even existed; indeed, I doubt the concept would even have entered my brain that anyone would seriously question the safety and efficacy of vaccines, which are one of the safest and most efficacious preventative medical interventions humans have ever devised, arguably having saved more lives than any other medical intervention ever conceived. Even six years ago, although I had become aware of the existence of the anti-vaccine movement, I considered them a small bunch of cranks so far into the woo that they weren’t really worth bothering with. Yes, I was a shruggie.

All of that changed not long after I started my first blog in December 2004. Approximately six months later, to be precise. That was when someone as famous as Robert F. Kennedy, Jr. published an infamous screed simultaneously in Rolling Stone and Salon.com entitled Deadly Immunity that was so full of misinformation, pseudoscience, and conspiracy mongering that it altered the course of my blogging forever. Although I had already been becoming less and less of a “shruggie” about the anti-vaccine movement before RFK’s propaganda piece, “Deadly Immunity” resulted in a significant percentage of my blogging turning to discussions of the anti-vaccine movement and the scientifically-discredited myth that vaccines cause autism.

Anti-vaccine, not pro-safe vaccine

Before I try to define “anti-vaccine” in more detail, I should take a moment to point out that, if there’s one thing I’ve learned in nearly six years blogging about vaccines and the pseudoscience used to attack them, it’s that no one — well, almost no one — considers himself “anti-vaccine.” This is very easily verifiable in the outraged reaction elicited from people like J.B. Handley (who simultaneously gloats about the decline in confidence in vaccines among parents), Jenny McCarthy, and Dr. Jay Gordon when they are described as “anti-vaccine. Jenny McCarthy, for instance, will reliably retort, “I’m not ‘anti-vaccine.’ I’m pro-safe vaccine.” An alternative response is, “What I really am is ‘anti-toxins’ in the vaccines.” Meanwhile, Dr. Gordon will say the same thing while simultaneously saying that he doesn’t give a lot of vaccines and foolishly admitting in the comments of a blog post that some parents have actually had to persuade him to vaccinate “reluctantly.”

The rule that those holding anti-vaccine views will rarely admit that they are anti-vaccine is a good one, although there are exceptions. It is not uncommon to find in the comments of anti-vaccine propaganda blogs likeAge of Autism and anti-vaccine mailing lists comments proclaiming explicit anti-vaccine views loud and proud, with declarations that “I am anti-vaccine.” This dichotomy has at times caused problems for the more P.R.-savvy members of the anti-vaccine movement, as demonstrated two years ago at Jenny McCarthy’s “Green Our Vaccines” rally, where images of vaccines as toxic waste and weapons of mass destruction were commonplace. Even so, the “Green Our Vaccines” slogan and coopting the “vaccine safety” mantle have been very effective for the anti-vaccine movement. In particular, Barbara Loe Fisher has successfully portrayed her National Vaccine Information Center (NVIC) as being a “vaccine safety watchdog” group looking out for parents’ rights, this despite hosting an online memorial for vaccine victims and a deceptive and disingenuous vaccine ingredient calculator.

“I know it when I see it”

In a concurring opinion in Jacobellis v. Ohio, regarding possible obscenity in a movie, Justice Potter Stewart once famously wrote:

I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description [“hard-core pornography”]; and perhaps I could never succeed in intelligibly doing so. But I know it when I see it, and the motion picture involved in this case is not that.

From my perspective, defining what is “anti-vaccine” is a lot like defining obscenity: I know it when I see it. However, as in the case of pornography, even though it’s quite true that what is anti-vaccine is in general easily identifiable to those of us who pay attention to such matters, it’s much more difficult to define in a way that those who don’t pay attention to the issue can recognize. This difficulty is complicated by the fact that there are a number of different flavors of anti-vaccine views ranging from (I kid you not) the view that vaccines are a tool of Satan todepopulate the earth to much milder views. It’s also important to realize that most parents who buy into anti-vaccine views do so out of ignorance, because they have been misled, rather than due to stupidity. When I “go medieval” on anti-vaccine activists, my ire is almost always reserved for the leaders of the anti-vaccine movement, who spread misinformation.

When I’m actually in an exchange with someone whom I suspect of having anti-vaccine views, one rather reliable way of differentiating fear from real anti-vaccine views is to ask a simple question: Which vaccines do you think that, barring medical contraindications, children should receive? If the answer is “none,” then I’m pretty much done. I know I’m almost certainly dealing with an anti-vaccinationist. Be aware that this question may require some pushing to get an answer. Rarely am I able to get a definitive answer on the first try, because most anti-vaccine advocates are cleverer than that. They realize that I’m trying to get them to admit that they are anti-vaccine. Even so, if I ask something like, “If you had it to do all over again, would you vaccinate your child?” or “If you have another child, will you vaccinate that child?” I will usually get the candid response I’m looking for.

“Vaccines don’t work”? “Vaccines are dangerous”? They’re both!

If you look at the types of arguments used to oppose vaccination, they will almost always boil down to two different flavors, either that vaccines don’t work or that vaccines are somehow dangerous. Of course, we discuss the latter argument here all the time when we point out studies that refute the alleged link between vaccines and autism. Like the slogan “Tastes great, less filling,” both of these claims often co-exist to differing degrees, with some anti-vaccinationists arguing that both are true: Vaccines don’t work and they are dangerous.

This being the real world, one has to remember that vaccines are not perfect. They are not 100% effective, and there can be rare serious side effects. What differentiates anti-vaccine cranks from, for example, scientists who deal with issues of efficacy versus side effects and potential complications all the time, is exaggeration far beyond what the scientific data will support. For example, if the influenza vaccine is less efficacious than perhaps we would like (which is true), then it must be useless. This is, in essence, the Nirvana fallacy, wherein if something is not perfect it is claimed to be utterly worthless. Part and parcel of this approach involves the complement, namely vastly exaggerating the potential side effects and complications due to vaccines to paint them as being far more dangerous than the diseases they prevent. In addition, anti-vaccine activists frequently attribute harms to vaccines that the existing scientific data definitely don’t support as being reasonable or legitimate. The claim that vaccines cause autism is the most famous, but far from the only one of these sorts of claims. It’s not uncommon to hear fallacious claims that vaccines cause autoimmune diseases, asthma, and a general “weakening” of the immune system, among others.

One of the most famous examples of exaggerated harm or nonexistent risks is the infamous “toxin” gambit. This fallacious argument claims that there are all sorts of scary chemicals in vaccines. Of course, there are all sorts of chemicals with scary names in vaccines, just as there are all sorts of chemicals with scary names in almost everything, from food to clothing to household cleaners, among others. The dose makes the poison, and the amounts of these chemicals, such as formaldehyde, are tiny. As we’ve pointed out time and time again, for instance, the amount of formaldehyde in vaccines is so tiny that it’s overwhelmed by the amount of formaldehyde made as a byproduct of normal metabolism. Then, of course, there are the chemicals claimed to be in vaccines that are, in fact, not in vaccines. The most famous of these is undoubtedly the infamous “antifreeze in vaccines” gambit. Finally, there is the claim that there are “aborted fetal parts” in vaccines. This particular claim comes from the fact that, for some vaccines, the viruses used to make the vaccines are grown in a human cell line derived from an aborted fetus.

Overall, the “tastes great, less filling”-type anti-vaccine claims that vaccines are dangerous and don’t work, can be differentiated from scientifically valid concerns about the efficacy and safety of vaccines on the basis of how evidence is treated and the types of arguments that are used. Scientists, of course, tend to be a lot more measured and express the level of uncertainty in their claims; anti-vaccine activists are under no such constraints. When, for example, scientists debated how to respond to the H1N1 pandemic last year, there was considerable uncertainty about how to do it, when to do it, and how to formulate the vaccines. Which adjuvants? Should we use squalene in order to decrease the amount of antigen used? Contrast this to the anti-vaccine arguments, which tended to argue that H1N1 wasn’t harmful, that the vaccine was toxic and wouldn’t work, and even that it was a New World Order plot.